Malingering of post-traumatic stress disorder

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Short description: Feigning PTSD for ulterior motives

Because of the substantial benefits available to individuals with a confirmed PTSD diagnosis, which causes occupational impairment, the distinct possibility of false diagnoses exist, some of which are due to malingering of PTSD. Post-traumatic stress disorder (PTSD) is a mental disorder that may develop after an individual experiences a traumatic event.[1] Malingering of PTSD consists of one feigning the disorder. In the United States, the Social Security Administration and the Department of Veterans Affairs each offer disability compensation programs that provide benefits for qualified individuals with mental disorders, including PTSD. These benefits can be substantial, making them attractive for those seeking financial gain.[2] Concerns about individuals exploiting benefits can lead to restricted access to these resources, inadvertently making it more difficult for those with PTSD who genuinely need assistance to receive it.[3] Malingering can lead to a decline in research and subsequent treatment for PTSD as it interferes with true studies. False data skews findings, making it more difficult to develop effective treatments.[4] Insurance fraud may also come about through malingering, burdening the economy, healthcare systems, and taxpayers.[5]

## Contents

* 1 Prevalence
* 2 Motivation
* 3 Consequences
* 4 Psychological assessment findings
* 4.1 Limitations
* 5 References

## Prevalence

The prevalence of malingering PTSD varies based on what one may be seeking. Differentiating between forensic and non-forensic evaluations, it has been found that malingering may be attempted in 15.7 percent of forensic evaluations and 7.4 percent of non-forensic evaluations.[6] As mentioned above, personal injury lawsuits can motivate someone to malinger PTSD. It is thought that between 20 and 30 percent of these people seeking settlements have malingered their PTSD results. It is also believed that a minimum of 20 percent of veterans seeking combat compensation have malingered.[7]

Cases within the criminal justice system also vary. A malingering rate between 8 percent and 17.4 percent was found in subjects in competency to stand trial assessments. Of incarcerated individuals seeking psychiatric services, a much higher range between 45 percent and 56 percent were suspected to malinger. Malingering cases were also positively correlated with severity of the crimes for subjects in competency to stand trial assessments. The incidence of malingering among individuals accused of murder or robbery is more than twice that of other subjects evaluated for competency.[8]

## Motivation

Individuals who malinger PTSD may have several motivations for doing so. First, financial incentives are common. For example, the Department of Veterans Affairs offers substantial annual financial compensation to U.S. veterans who can prove that they have PTSD related to their military service. This potential compensation can create an incentive for veterans to malinger PTSD, especially in cases where financial instability or perceived injustice might drive individuals to falsify symptoms.[9] Military personnel may avoid their military duty due to malingering PTSD, leading to a misuse of military resources, affecting unit readiness, and placing a greater burden on fellow service members.[10] Furthermore, the U.S. Social Security Administration offers social security disability payments to individuals documenting a disorder such as PTSD that impedes their ability to work, which additionally provides an incentive to malinger PTSD.[11] Additionally, the potential for workers compensation can motivate individuals reporting a traumatic event at their workplace to fabricate PTSD; and finally the potential for personal injury lawsuits can motivate someone to malinger PTSD and sue an individual for causing PTSD as a result of attack, accident or other stressor.[12]

Some individuals are known to malinger PTSD to obtain inpatient hospital treatment.[13] In such cases, individuals may manipulate the system to gain access to care that they believe they need or may do so to escape external responsibilities or difficulties.[14] Persons charged in criminal law cases are motivated to malinger PTSD in order to offset criminal responsibility for the crime or mitigate the associated penalties; this not only complicates legal proceedings, but can undermine genuine cases of mental-health related defenses.[15] In some cases, individuals may feign PTSD, particularly within military and combat settings, to seek accolades and recognition from their peers.[16]

## Consequences

Malingering can significantly divert resources away from individuals who legitimately suffer from PTSD.[17] This diversion not only delays and reduces their access to necessary treatments and support but also consumes resources and time that could be more effectively used for treating genuine cases. As a result, this can lead to inefficiencies and increased costs within healthcare and mental health systems.[18] This can increase expenses and impact the availability and quality of mental health services. Malingering can complicate legal cases and insurance claims, which leads to higher litigation costs and delays in settlements.[19]

Malingering cases can also lead to increased skepticism towards individuals claiming to have PTSD and contribute to the stigmatization of those with genuine PTSD. This may cause stress and anxiety due to the suspicion of malingering, thus exacerbating their symptoms.[20] On a societal level, malingering can erode public trust in mental health and disability systems by increasing skepticism and resistance to supporting mental health initiatives.[21]

Individuals who are found to be malingering may face legal consequences, including criminal charges, fines, or imprisonment.[22] Individuals' reputations and credibility can be impacted along with their personal and professional lives. Those found malingering can deal with difficulties when taking legal actions or dealing with future claims.[18]

## Psychological assessment findings

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is a self-reported personality test which is the most widely used psychological assessment measure in research to detect malingered PTSD, typically by comparing genuine PTSD patients with individuals trained and instructed to fabricate PTSD on the MMPI-2.[23] Numerous studies using the MMPI-2 have demonstrated a moderately accurate ability to detect feigned PTSD.[24][25][26][27][28][29][30] Validity scales on the MMPI-2 that are reasonably accurate at detecting simulated PTSD include both the Fp scale developed by Paul Arbisi and Yosef Ben-Porath,[31] and the Fptsd scale developed by Jon Elhai for combat survivors.[26] These two scales have shown differing results. The Fp scale is the most helpful malingering predictor in civilian PTSD patients, whereas the Fptsd scale is a better predictor in combat PTSD patients.[32]

The Symptom Validity Test (SVT) comprises two distinct measures designed to diagnose malingering PTSD and assess the credibility of reported PTSD symptoms.[33] Studies show that SVTs are effective in distinguishing between genuine and feigned symptoms in various settings. The Performance Validity Test (PVT) evaluates the credibility of an individual's performance on cognitive or neuropsychological tests. PVTs are crucial for identifying instances where individuals may fabricate or exaggerate cognitive impairments related to PTSD. Additionally, PVTs are widely validated and used in various assessments by complementing other assessments tools by providing additional evidence.[34]

While other psychological assessments, such as the Personality Assessment Inventory[35][36] and Trauma Symptom Inventory[30][37][38] have been explored for detecting PTSD malingering, none have matched the MMPI-2's accuracy rates. The current literature modestly supports the effectiveness of the Personality Assessment Inventory or PAI at detecting malingering of post-traumatic stress disorder or PTSD. Although results are mixed, the validity indicators of the PAI have been found to be effective at differentiating malingered PTSD from a diagnostically supported diagnosis of PTSD. Specifically, the negative impression management or NIM scale, the malingering index scale or MAL, and the negative distortion validity scale or NDS of the PAI are interpreted in detecting malingering of PTSD.[39][40]

Using a combination of assessments is critical when evaluating PTSD malingering, rather than relying solely on a single test.[41] A preliminary test which can be used is the Miller-Forensic Assessment of Symptoms (M-FAST). It can find 78 percent of test-takers asked to feign results and only takes between 5 and 10 minutes.[42] Interviews hosted by clinicians are sometimes preferred over self-reported tests. These include the Clinician-Administered PTSD Scale (CAPS) or the Structured Interview of Reported Symptoms-2 (SIRS-2).[43][44] Each of these include and interviewer who asks an interviewee a series of questions. The CAPS asks interviewees to rate items on a scale while the SIRS-2 may ask questions that could elicit a response that would expose malingering. The SIRS-2 has high accuracy in general malingering and PTSD malingering.[45]

### Limitations

Many studies on malingering PTSD focus on specific populations, mostly being veterans, which limits generalizability to more diverse groups. Most studies and research on malingering PTSD are concentrated in Western countries, specifically the United States. This overlooks other cultures and ethnicities.[46]

Assessment tools for malingering like the MMPI-2, PAI, and other tests, vary in levels of accuracy depending on the context and population. The effectiveness of these tests differs, thus leading to potential inconsistencies in malingering detection.[47] Some tools used to assess malingering PTSD may be outdated and some of the research articles have used these outdated tools for their research. These malingering PTSD assessments often involve subjective elements with self-reporting items.[48] This subjectivity can impact the reliability and validity of malingering assessment.[49]

## References

1. ↑ Diagnostic and statistical manual of mental disorders. (5 ed.). Washington, D.C.: American Psychiatric Association. 2013. ISBN 978-0-89042-555-8. https://archive.org/details/diagnosticstatis0005unse. "A person was exposed to one or more event(s) that involved death or threatened death, actual or threatened serious injury, or threatened sexual violation."
2. ↑ Alozai, Ubaid ullah; McPherson, Pamela K. (2024), "Malingering", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 29939614, https://www.ncbi.nlm.nih.gov/books/NBK507837/#:~:text=Malingering is falsification or profound,from a job, among others., retrieved 2024-10-19
3. ↑ Stines, Lisa R. (2007-03-10). "Clinician's Guide to PTSD: A Cognitive-Behavioral Approach. Steven Taylor, Guilford Press, 2006, 322 pp, $35.00". Journal of Contemporary Psychotherapy 37 (2): 113–114. doi:10.1007/s10879-006-9044-7. ISSN 0022-0116.
4. ↑ Rosen, Gerald M. (January 2006). "DSM's cautionary guideline to rule out malingering can protect the PTSD data base" (in en). Journal of Anxiety Disorders 20 (4): 530–535. doi:10.1016/j.janxdis.2005.03.004. PMID 15908176. https://linkinghub.elsevier.com/retrieve/pii/S0887618505000502.
5. ↑ Ali, Shahid (2015). "Multimodal Approach to Identifying Malingered Posttraumatic Stress Disorder: A Review". Innovations in Clinical Neuroscience 12 (1–2): 12–20. PMID 25852974.
6. ↑ Matto, Mikel; McNiel, Dale E.; Binder, Renée L. (2019-06-10). "A Systematic Approach to the Detection of False PTSD" (in en). Journal of the American Academy of Psychiatry and the Law Online 47 (3): 325–334. doi:10.29158/JAAPL.003853-19. ISSN 1093-6793. PMID 31182437. https://jaapl.org/content/early/2019/06/10/JAAPL.003853-19.
7. ↑ Taylor, Steven; Frueh, B. Christopher; Asmundson, Gordon J. G. (2007-01-01). "Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: Methods, obstacles, and recommendations" (in en). Journal of Anxiety Disorders 21 (1): 22–41. doi:10.1016/j.janxdis.2006.03.016. ISSN 0887-6185. PMID 16647834. https://www.sciencedirect.com/science/article/pii/S0887618506000533.
8. ↑ McDermott, Barbara E.; Dualan, Isah V.; Scott, Charles L. (2013-05-01). "Malingering in the correctional system: Does incentive affect prevalence?" (in en). International Journal of Law and Psychiatry. Special Issue on Prisons and Mental Health 36 (3): 287–292. doi:10.1016/j.ijlp.2013.04.013. ISSN 0160-2527. PMID 23664364. https://www.sciencedirect.com/science/article/pii/S0160252713000356.
9. ↑ Frueh, B. C.; Grubaugh, A. L.; Elhai, J. D.; Buckley, T. C. (2007). "US Department of Veterans Affairs disability policies for posttraumatic stress disorder: Administrative trends and implications for treatment, rehabilitation, and research". American Journal of Public Health 97 (12): U2143–2145. doi:10.2105/AJPH.2007.115436. PMID 17971542.
10. ↑ Malingering mental disorders: Clinical assessment
11. ↑ Taylor, S.; Frueh, B. C.; Asmundson, G. J. G. (2007). "Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: Methods, obstacles, and recommendations". Journal of Anxiety Disorders 21 (1): 22–41. doi:10.1016/j.janxdis.2006.03.016. PMID 16647834.
12. ↑ Guriel, J.; Fremouw, W. (2003). "Assessing malingered posttraumatic stress disorder: A critical review". Clinical Psychology Review 23 (7): 881–904. doi:10.1016/j.cpr.2003.07.001. PMID 14624820.
13. ↑ Salloway, S.; Southwick, S.; Sadowsky, M. (1990). "Opiate withdrawal presenting as posttraumatic stress disorder". Hospital and Community Psychiatry 41 (6): 666–667. doi:10.1176/ps.41.6.666. PMID 2361672. http://ps.psychiatryonline.org/cgi/content/citation/41/6/666.
14. ↑ Alozai, Ubaid ullah; McPherson, Pamela K. (2024), "Malingering", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 29939614, https://www.ncbi.nlm.nih.gov/books/NBK507837/#:~:text=Malingering is falsification or profound,from a job, among others., retrieved 2024-10-19
15. ↑ Resnick, P. J.; West, S.; Payne, J. W. (2008). "Malingering of posttraumatic disorders". in Rogers, R.. Clinical assessment of malingering and deception (3rd ed.). Guilford Press. pp. 109–127. ISBN 978-1-59385-699-1.
16. ↑ Burkett, B. G.; Whitley, G. (1998). Stolen valor: How the Vietnam generation was robbed of its heroes and history. Verity Press. ISBN 978-0-9667036-0-3.
17. ↑ Ali, Shahid (2015). "Multimodal Approach to Identifying Malingered Posttraumatic Stress Disorder: A Review". Innovations in Clinical Neuroscience 12 (1–2): 12–20. PMID 25852974.
18. ↑ 18.0 18.1 Alozai, Ubaid ullah; McPherson, Pamela K. (2024), "Malingering", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 29939614, https://www.ncbi.nlm.nih.gov/books/NBK507837/, retrieved 2024-07-26
19. ↑ Weiss, Kenneth J.; Van Dell, Landon (2017-09-01). "Liability for Diagnosing Malingering" (in en). Journal of the American Academy of Psychiatry and the Law Online 45 (3): 339–347. ISSN 1093-6793. PMID 28939732. https://jaapl.org/content/45/3/339.
20. ↑ Biegańska-Banaś, J.; Banaś, P.; Zięba, M.; Gierowski, J.K.; Trzebiński, J. (May 2023). "PTSD malingering detection in damage claim cases: Diagnostic accuracy in cases of personal injury as a result of motor vehicle accidents". International Journal of Law and Psychiatry 88. doi:10.1016/j.ijlp.2023.101885. ISSN 0160-2527. PMID 36989590. https://ruj.uj.edu.pl/xmlui/handle/item/310599.
21. ↑ Matto, Mikel; McNiel, Dale E.; Binder, Renée L. (2019-06-10). "A Systematic Approach to the Detection of False PTSD" (in en). Journal of the American Academy of Psychiatry and the Law Online 47 (3): 325–334. doi:10.29158/JAAPL.003853-19. ISSN 1093-6793. PMID 31182437. https://jaapl.org/content/early/2019/06/10/JAAPL.003853-19.
22. ↑ Clinical assessment of malingering and deception (4th ed.). The Guilford Press. 2018. https://psycnet.apa.org/record/2018-11350-000.
23. ↑ Demakis, G. J.; Elhai, J. D. (2011). "Neuropsychological and psychological aspects of malingered posttraumatic stress disorder". Psychological Injury and Law 4: 24–31. doi:10.1007/s12207-011-9099-y.
24. ↑ Elhai, J. D.; Gold, S. N.; Sellers, A. H.; Dorfman, W. I. (June 2001). "The detection of malingered posttraumatic stress disorder with MMPI-2 fake bad indices". Assessment 8 (2): 221–236. doi:10.1177/107319110100800210. PMID 11428701.
25. ↑ Elhai, J. D.; Gold, P. B.; Frueh, B. C.; Gold, S. N. (2000). "Cross-validation of the MMPI-2 in detecting malingered posttraumatic stress disorder". Journal of Personality Assessment 75 (3): 449–463. doi:10.1207/S15327752JPA7503_06. PMID 11117156.
26. ↑ 26.0 26.1 Elhai, J. D.; Ruggiero, K. J.; Frueh, B. C.; Beckham, J. C.; Gold, P. B.; Feldman, M. E. (December 2002). "The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: Development and initial validation with veterans presenting with combat-related PTSD". Journal of Personality Assessment 79 (3): 531–549. doi:10.1207/S15327752JPA7903_08. PMID 12511019.
27. ↑ Elhai, J. D.; Naifeh, J. A.; Zucker, I. S.; Gold, S. N.; Deitsch, S. E.; Frueh, B. C. (2004). "Discriminating malingered from genuine civilian posttraumatic stress disorder: A validation of three MMPI-2 infrequency scales (F, Fp, and Fptsd)". Assessment 11 (2): 139–144. doi:10.1177/1073191104264965. PMID 15171461.
28. ↑ Arbisi, P. A.; Ben-Porath, Y. S.; McNulty, J. (2006). "The ability of the MMPI-2 to detect feigned PTSD within the context of compensation seeking". Psychological Services 3 (4): 249–261. doi:10.1037/1541-1559.3.4.249.
29. ↑ Marshall, M. B.; Bagby, R. M. (December 2006). "The incremental validity and clinical utility of the MMPI-2 Infrequency Posttraumatic Stress Disorder Scale". Assessment 13 (4): 417–429. doi:10.1177/1073191106290842. PMID 17050912.
30. ↑ 30.0 30.1 Efendov, A. A.; Sellbom, M.; Bagby, R. M. (2008). "The utility and comparative incremental validity of the MMPI-2 and Trauma Symptom Inventory validity scales in the detection of feigned PTSD". Psychological Assessment 20 (4): 317–326. doi:10.1037/a0013870. PMID 19086755.
31. ↑ Arbisi, P. A.; Ben-Porath, Y. S. (1995). "An MMPI-2 infrequent response scale for use with psychopathological populations: The Infrequency Psychopathology scale, F(p)". Psychological Assessment 7 (4): 424–431. doi:10.1037/1040-3590.7.4.424.
32. ↑ Matto, Mikel; McNiel, Dale E.; Binder, Renée L. (2019-06-10). "A Systematic Approach to the Detection of False PTSD" (in en). Journal of the American Academy of Psychiatry and the Law Online 47 (3): 325–334. doi:10.29158/JAAPL.003853-19. ISSN 1093-6793. PMID 31182437. https://jaapl.org/content/early/2019/06/10/JAAPL.003853-19.
33. ↑ Rosen, Gerald M.; Powel, Jeffrey E. (2003-01-01). "Use of a Symptom Validity Test in the forensic assessment of Posttraumatic Stress Disorder". Journal of Anxiety Disorders 17 (3): 361–367. doi:10.1016/S0887-6185(02)00200-1. ISSN 0887-6185. PMID 12727128. https://linkinghub.elsevier.com/retrieve/pii/S0887618502002001.
34. ↑ Ord, Anna S.; Shura, Robert D.; Sansone, Ashley R.; Martindale, Sarah L.; Taber, Katherine H.; Rowland, Jared A. (March 2021). "Performance validity and symptom validity tests: Are they measuring different constructs?" (in en). Neuropsychology 35 (3): 241–251. doi:10.1037/neu0000722. ISSN 1931-1559. PMID 33829824.
35. ↑ Eakin, D. E.; Weathers, F. W.; Benson, T. B.; Anderson, C. F.; Funderbunk, B. (2006). "Detection of feigned posttraumatic stress disorder: A comparison of the MMPI-2 and PAI". Journal of Psychopathology and Behavioral Assessment 28 (3): 145–155. doi:10.1007/s10862-005-9006-5.
36. ↑ Lange, R. T.; Sullivan, K. A.; Scott, C. (2010). "Comparison of MMPI-2 and PAI validity indicators to detect feigned depression and PTSD symptom reporting". Psychiatry Research 176 (2–3): 229–235. doi:10.1016/j.psychres.2009.03.004. PMID 20207423. https://eprints.qut.edu.au/18484/1/c18484.pdf.
37. ↑ Elhai, J. D.; Gray, M. J.; Naifeh, J. A.; Butcher, J. J.; Davis, J. L.; Falsetti, S. A.; Best, C. L. (June 2005). "Utility of the Trauma Symptom Inventory's Atypical Response Scale in detecting malingered post-traumatic stress disorder". Assessment 12 (2): 210–219. doi:10.1177/1073191105275456. PMID 15914722.
38. ↑ Rogers, R.; Payne, J. W.; Correa, A. A.; Gillard, N. D.; Ross, C. A. (2009). "A study of the SIRS with severely traumatized patients". Journal of Personality Assessment 91 (5): 429–438. doi:10.1080/00223890903087745. PMID 19672749.
39. ↑ Thomas, Katherine M.; Hopwood, Christopher J.; Orlando, Mathew J.; Weathers, Frank W.; McDevitt-Murphy, Meghan E. (2012-12-01). "Detecting Feigned PTSD Using the Personality Assessment Inventory" (in en). Psychological Injury and Law 5 (3): 192–201. doi:10.1007/s12207-011-9111-6. ISSN 1938-9728.
40. ↑ Rogers, Richard; Gillard, Nathan D.; Wooley, Chelsea N.; Ross, Colin A. (2012-03-01). "The Detection of Feigned Disabilities: The Effectiveness of the Personality Assessment Inventory in a Traumatized Inpatient Sample" (in en). Assessment 19 (1): 77–88. doi:10.1177/1073191111422031. ISSN 1073-1911. PMID 21954300.
41. ↑ Wooley, Chelsea N.; Rogers, Richard (August 2015). "The Effectiveness of the Personality Assessment Inventory With Feigned PTSD: An Initial Investigation of Resnick's Model of Malingering" (in en). Assessment 22 (4): 449–458. doi:10.1177/1073191114552076. ISSN 1073-1911. PMID 25268016. http://journals.sagepub.com/doi/10.1177/1073191114552076.
42. ↑ Messer, Julia M.; Fremouw, William J. (2007-09-20). "Detecting Malingered Posttraumatic Stress Disorder Using the Morel Emotional Numbing Test-Revised (MENT-R) and the Miller Forensic Assessment of Symptoms Test (M-FAST)" (in en). Journal of Forensic Psychology Practice 7 (3): 33–57. doi:10.1300/J158v07n03_02. ISSN 1522-8932. http://www.tandfonline.com/doi/abs/10.1300/J158v07n03_02.
43. ↑ "VA.gov | Veterans Affairs" (in en). https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp.
44. ↑ Weiner, Irving B., ed (2010-01-30) (in en). The Corsini Encyclopedia of Psychology (1 ed.). Wiley. doi:10.1002/9780470479216.corpsy0957. ISBN 978-0-470-17024-3. https://onlinelibrary.wiley.com/doi/book/10.1002/9780470479216.
45. ↑ Taylor, Steven; Frueh, B. Christopher; Asmundson, Gordon J. G. (2007-01-01). "Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: Methods, obstacles, and recommendations" (in en). Journal of Anxiety Disorders 21 (1): 22–41. doi:10.1016/j.janxdis.2006.03.016. ISSN 0887-6185. PMID 16647834. https://www.sciencedirect.com/science/article/pii/S0887618506000533.
46. ↑ Wolf, Erika J.; Ellickson-Larew, Stephanie; Guetta, Rachel E.; Escarfulleri, Shaline; Ryabchenko, Karen; Miller, Mark W. (2020-09-01). "Psychometric Performance of the Miller Forensic Assessment of Symptoms Test (M-FAST) in Veteran PTSD Assessment" (in en). Psychological Injury and Law 13 (3): 284–302. doi:10.1007/s12207-020-09373-y. ISSN 1938-9728. PMID 32431781.
47. ↑ Young, Gerald (2017-05-01). "PTSD in Court III: Malingering, assessment, and the law". International Journal of Law and Psychiatry 52: 81–102. doi:10.1016/j.ijlp.2017.03.001. ISSN 0160-2527. PMID 28366496. https://www.sciencedirect.com/science/article/pii/S0160252717300596.
48. ↑ Ali, Shahid (2015). "Multimodal Approach to Identifying Malingered Posttraumatic Stress Disorder: A Review". Innovations in Clinical Neuroscience 12 (1–2): 12–20. PMID 25852974.
49. ↑ Bosso, Tea; Vischia, Flavio; Keller, Roberto; Vai, Daniela; Imperiale, Daniele; Vercelli, Alessandro (2022-10-14). "A case report and literature review of cognitive malingering and psychopathology". Frontiers in Psychiatry 13. doi:10.3389/fpsyt.2022.981475. ISSN 1664-0640. PMID 36311526.

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